History of Medicine / ENCYCLOPÆDIA BRITANNICA
Hellenistic
and Roman Medicine
In the following century
the work of Aristotle,
regarded as the first great biologist, was of inestimable value to medicine. A
pupil of Plato at Athens and tutor to Alexander the Great, Aristotle studied the
entire world of living things. He laid what can be identified as the foundations
of comparative anatomy and embryology,
and his views influenced scientific thinking for the next 2,000 years.
After the time of
Aristotle, the centre of Greek culture shifted to Alexandria,
where a famous medical school was established in about 300 BC. There, the two
best medical teachers were Herophilus,
whose treatise on anatomy may have been the first of its kind, and Erasistratus,
regarded by some as the founder of physiology. Erasistratus noted the difference
between sensory and motor nerves but thought that the nerves were hollow tubes
containing fluid and that air entered the lungs and heart and was carried
through the body in the arteries. Alexandria continued as a centre of medical
teaching even after the Roman Empire had attained supremacy over the Greek
world, and medical knowledge remained predominantly Greek.
Asclepiades
of Bithynia (born 124 BC) differed from Hippocrates in that he denied the
healing power of nature and insisted that disease should be treated safely,
speedily, and agreeably. An opponent of the humoral theory, he drew upon the
atomic theory of the 5th-century Greek philosopher Democritus in advocating a
doctrine of strictum et laxum--the attribution of disease to the
contracted or relaxed condition of the solid particles that he believed make up
the body. To restore harmony among the particles and thus effect cures,
Asclepiades used typically Greek remedies: massage, poultices, occasional
tonics, fresh air, and corrective diet. He gave particular attention to mental
disease, clearly distinguishing hallucinations from delusions. He released the
insane from confinement in dark cellars and prescribed a regimen of occupational
therapy, soothing music, soporifics (especially wine), and exercises to improve
the attention and memory.
Asclepiades did much to win
acceptance for Greek medicine in Rome. Aulus
Cornelius Celsus, the Roman nobleman who wrote De medicina about AD
30, gave a classic account of Greek medicine of the time, including descriptions
of elaborate surgical operations. His book, overlooked in his day, enjoyed a
wide reputation during the Renaissance.
During the early centuries
of the Christian Era, Greek doctors thronged to Rome. The most illustrious of
them was Galen,
who began practicing there in AD 161. He acknowledged his debt to Hippocrates
and followed the Hippocratic method, accepting the doctrine of the humours. He
laid stress on the value of anatomy, and he virtually founded experimental
physiology. Galen recognized that the arteries contain blood and not merely air.
He showed how the heart sets the blood in motion in an ebb and flow fashion, but
he had no idea that the blood circulates. Dissection of the human body was at
that time illegal, so that he was forced to base his knowledge upon the
examination of animals, particularly apes. A voluminous writer who stated his
views forcibly and with confidence, he remained for centuries the undisputed
authority from whom no one dared to differ.
Another influential
physician of the 2nd century AD was Soranus of Ephesus, who wrote
authoritatively on childbirth, infant care, and women's diseases. An opponent of
abortion, he advocated numerous means of contraception. He also described how to
assist a difficult delivery by turning the fetus in the uterus (podalic
version), a life-saving technique that was subsequently lost sight of until it
was revived in the 16th century.
Although the contribution
of Rome to the practice of medicine was negligible compared with that of Greece,
in matters of public health the Romans set the world a great example. The city
of Rome had an unrivaled water supply. Gymnasiums and public baths were
provided, and there was even domestic sanitation and adequate disposal of
sewage. The army had its medical officers, public physicians were appointed to
attend the poor, and hospitals were built; a Roman hospital excavated near Düsseldorf,
Ger., was found to be strikingly modern in design.
Christian and Muslim
reservoirs of learning
After the fall of Rome,
learning was no longer held in high esteem, experiment was discouraged, and
originality became a dangerous asset. During the early Middle
Ages medicine passed into the widely diverse hands of the Christian Church
and Arab scholars.
Translators and Saints
It is sometimes stated that
the early Christian Church had an adverse effect upon medical progress. Disease
was regarded as a punishment for sin, and such chastening demanded only prayer
and repentance. Moreover, the human body was held sacred and dissection was
forbidden. But the infinite care and nursing bestowed upon the sick under
Christian auspices must outweigh any intolerance shown toward medicine in the
early days.
Perhaps the greatest
service rendered to medicine by the church was the preservation and
transcription of the classical Greek medical manuscripts. These were translated
into Latin in many medieval monasteries, and the Nestorian
Christians (an Eastern church) established a school of translators to render the
Greek texts into Arabic. This famous school, and also a great hospital, were
located at Jundi Shahpur in southwest Persia, where the chief
physician was Jurjis ibn Bukhtishu', the first of a dynasty of
translators and physicians that lasted for six generations. A later translator
of great renown was Hunayn
ibn Ishaq, or Johannitus (born AD 809), whose translations were said to be
worth their weight in gold.
Arabian Medicine
A second reservoir of
medical learning during those times was the great Muslim empire, which extended
from Persia to Spain. Although it is customary to speak of Arabian medicine in
describing this period, not all of the physicians were Arabs or natives of
Arabia. Nor, indeed, were they all Muslims: some were Jews, some Christians, and
they were drawn from all parts of the empire. One of the earliest figures was Rhazes,
a Persian born in the last half of the 9th century near modern Tehran,
who wrote a voluminous treatise on medicine, Kitab al-haki
("Comprehensive Book"), but whose most famous work, De variolis et
morbillis (A Treatise on the Smallpox and Measles), distinguishes
between these two diseases and gives a clear description of both.
Of later date was Avicenna
(980-1037), also a Persian, who has been called the prince of physicians and
whose tomb at Hamadan has become a place of pilgrimage. He could repeat the Qur'an
before he was 10 years old and at the age of 18 became court physician. His
principal medical work, al-Qanun fi at-tibb (The
Canon of Medicine), became a classic and was used at many medical
schools--at Montpellier, Fr., as late as 1650--and reputedly is still used in
the East.
The greatest contribution
of Arabian medicine was in chemistry and in the knowledge and preparation of
medicines. The chemists of that time were alchemists, and their pursuit was
mainly a search for the philosopher's stone, which supposedly would turn common
metals into gold. In the course of their experiments, however, numerous
substances were named and characterized, and some were found to have medicinal
value. Many drugs now in use are of Arab origin, as are such processes as
distillation and sublimation.
At that period, and indeed
throughout most historical times, surgery was considered inferior to medicine,
and surgeons were held in low regard. The renowned Spanish surgeon Abu
al-Qasim (Albucasis), however, did much to raise the status of surgery in Córdoba,
an important centre of commerce and culture with a hospital and medical school
equal to those of Cairo and Baghdad. A careful and conservative practitioner, he
wrote the first illustrated surgical text, which held wide influence in Europe
for centuries.
Medieval and Renaissance Europe
Salerno
and the medical schools
At about the same time that
Arabian medicine flourished, the first organized medical school in Europe was
established at Salerno, in southern Italy. Although the school of Salerno
produced no brilliant genius and no startling discovery, it was the outstanding
medical institution of its time and the parent of the great medieval schools
soon to be founded at Montpellier and Paris, in France, and at Bologna and
Padua, in Italy. Salerno drew scholars from near and far. Remarkably liberal in
some of its views, Salerno admitted women as medical students. The school owed
much to the enlightened Holy Roman emperor Frederick
II, who decreed in 1221 that no one should practice medicine until he had
been publicly approved by the masters of Salerno.
The Salernitan school also
produced a literature of its own; the best-known work, of uncertain date and of
composite authorship, was the Regimen Sanitatis Salernitanum
("Salernitan Guide to Health"). Written in verse, it has appeared in
numerous editions and has been translated into many languages. Among its
oft-quoted couplets is the following:
Use three physicians still, first Doctor Quiet,
Next Doctor Merryman, and Doctor Diet.
Salerno yielded its place
as the premier medical school of Europe to Montpellier
in about 1200. John of Gaddesden, the model for the "doctour of
physick" in Chaucer's Canterbury
Tales, was one of the English students there. That he relied upon
astrology and upon the doctrine of the humours is evident from Chaucer's
description:
Well could he guess the ascending of the star
Wherein his patient's fortunes settled were.
He knew the course of every malady,
Were it of cold or heat or moist or dry.
Medieval physicians
analyzed symptoms, examined excreta, and made their diagnoses. Then they might
prescribe diet, rest, sleep, exercise, or baths; or they could administer
emetics and purgatives or bleed the patient. Surgeons could treat fractures and
dislocations, repair hernias, and perform amputations and a few other
operations. Some of them prescribed opium, mandragora, or alcohol to deaden
pain. Childbirth was left to midwives, who relied on folklore and tradition.
The roots of Western
Medicine
The transition from magic
to science was a gradual process that lasted for centuries, and there is little
doubt that ancient
Greece inherited much from Babylonia and Egypt, and even India and China.
Twentieth-century readers of the Homeric tales the Iliad and the Odyssey
may well be bewildered by the narrow distinction between gods and men among the
characters and between historical fact and poetic fancy in the story. Two
characters, the military surgeons Podaleirius and Machaon, are said to have been
sons of Asclepius,
the god of medicine. The divine Asclepius may have originated in a human
Asclepius who lived about 1200 BC and is said to have performed many miracles of
healing.
Asclepius was worshiped in
hundreds of temples throughout Greece, the remains of which may still be seen at
Epidaurus, Cos, Athens, and elsewhere. To these resorts, or hospitals, sick
persons went for the healing ritual known as incubation,
or temple sleep. They lay down to sleep in the dormitory, or abaton, and
were visited in their dreams by Asclepius or by one of his priests, who gave
advice. In the morning the patient often is said to have departed cured. There
are at Epidaurus
many inscriptions recording cures, though there is no mention of failures or
deaths.
Diet, baths, and exercises
played their part in the treatment, and it would appear that these temples were
the prototype of modern health resorts. Situated in a peaceful spot, with
gardens and fountains, each had its theatre for amusements and its stadium for
athletic contests. The cult of incubation continued far into the Christian Era.
In Greece, some of the Aegean islands, Sardinia, and Sicily, sick persons are
still taken to spend a night in certain churches in the hope of a cure.
It was, however, the work
of the early philosophers, rather than that of the priests of Asclepius, that
impelled Greeks to refuse to be guided solely by supernatural influence and
moved them to seek out for themselves the causes and reasons for the strange
ways of nature. The 6th-century philosopher Pythagoras,
whose chief discovery was the importance of numbers, also investigated the
physics of sound, and his views influenced the medical thought of his time. In
the 5th century BC Empedocles
set forth the view that the universe is composed of four elements--fire, air,
earth, and water; this conception led to the doctrine of the four bodily humours:
blood; phlegm; choler, or yellow bile; and melancholy, or black bile. The
maintenance of health was held to depend upon the harmony of the four humours.
Medical thought had reached
this stage and had partially discarded the conceptions based upon magic and
religion by 460 BC, the year that Hippocrates is said to have been born.
Although he has been called the father of medicine, little is known of his life,
and there may, in fact, have been several men of this name; or Hippocrates may
have been the author of only some, or none, of the books that make up the Hippocratic
Collection (Corpus Hippocraticum). Ancient writers held that
Hippocrates taught and practiced medicine in Cos,
the island of his birth, and in other parts of Greece, including Athens, and
that he died at an advanced age.
Whether Hippocrates was one
man or several, the works attributed to him mark the stage in Western medicine
where disease was coming to be regarded as a natural rather than a supernatural
phenomenon and doctors were encouraged to look for physical causes of illness.
Some of the works, notably the Aphorismi (Aphorisms), were used as
textbooks until the 19th century. The first and best-known aphorism is,
"Life is Short, Art long, Occasion sudden and dangerous, Experience
deceitful, and Judgment difficult" (often shortened to the Latin tag,
"Ars longa, vita brevis"). This is followed by brief comments on
diseases and symptoms, many of which remain valid.
The thermometer and the
stethoscope were not then known; nor, indeed, did Hippocrates employ any aid to
diagnosis beyond his own powers of observation and logical reasoning. He had an
extraordinary ability to foretell the course of a malady, and he laid more
stress upon the expected outcome, or prognosis, of a disease than upon its
identification, or diagnosis. He had no patience with the idea that disease was
a punishment sent by the gods. Writing of epilepsy,
then called "the sacred disease," he said, "It is not any more
sacred than other diseases, but has a natural cause, and its supposed divine
origin is due to man's inexperience. Every disease," he continued,
"has its own nature, and arises from external causes."
Hippocrates noted the
effect of food, of occupation, and especially of climate in causing disease, and
one of his most interesting books, entitled De aëre, aquis et locis (Air,
Waters and Places), would today be classed as a treatise on human
ecology. Pursuing this line of thought, Hippocrates stated that "our
natures are the physicians of our diseases" and advocated that this
tendency to natural cure should be fostered. He laid much stress on diet and the
use of few drugs. He knew well how to describe illness clearly and concisely and
recorded failures as well as successes; he viewed disease with the eye of the
naturalist and studied the entire patient in his environment.
Perhaps the greatest legacy
of Hippocrates is the charter of medical
conduct embodied in the so-called Hippocratic
oath, which has been adopted as a pattern by physicians throughout the ages:
I swear by Apollo the physician, and Asclepius, and Health,
and All-heal, and all the gods and goddesses . . . to reckon him who taught me
this Art equally dear to me as my parents, to share my substance with him, and
relieve his necessities if required; to look upon his offspring in the same
footing as my own brothers, and to teach them this art, if they shall wish to
learn it, without fee or stipulation; and that by precept, lecture, and every
other mode of instruction, I will impart a knowledge of the Art to my own sons,
and those of my teachers, and to disciples bound by a stipulation and oath
according to the law of medicine, but to none others. I will follow that system
of regimen which, according to my ability and judgment, I consider for the
benefit of my patients, and abstain from whatever is deleterious and
mischievous. I will give no deadly medicine to any one if asked, nor suggest any
such counsel; and in like manner I will not give to a woman a pessary to produce
abortion. . . . Into whatever houses I enter, I will go into them for the
benefit of the sick, and will abstain from every voluntary act of mischief and
corruption; and, further from the seduction of females or males, of freemen and
slaves. Whatever, in connection with my professional practice or not, in
connection with it, I see or hear, in the life of men, which ought not to be
spoken of abroad, I will not divulge, as reckoning that all such should be kept
secret.
The ancient Middle East
and Egypt
The establishment of the
calendar and the invention of writing marked the dawn of recorded history. The
clues to early knowledge are scanty, consisting of clay tablets bearing
cuneiform signs and seals that were used by physicians of ancient Mesopotamia.
In the Louvre there is preserved a stone pillar on which is inscribed the Code
of Hammurabi, who was a Babylonian
king of the 18th century BC. This code includes laws relating to the practice of
medicine, and the penalties for failure were severe. For example, "If the
doctor, in opening an abscess, shall kill the patient, his hands shall be cut
off"; if, however, the patient was a slave, the doctor was simply obliged
to supply another slave.
The Greek historian
Herodotus stated that every Babylonian was an amateur physician, since it was
the custom to lay the sick in the street so that anyone passing by might offer
advice. Divination,
from the inspection of the liver of a sacrificed animal, was widely practiced to
foretell the course of a disease. Little else is known regarding Babylonian
medicine, and the name of not a single physician has survived.
When the medicine of ancient
Egypt is examined, the picture becomes clearer. The first physician to
emerge is Imhotep,
chief minister to King Djoser in the 3rd millennium BC, who designed one of the
earliest pyramids, the Step Pyramid at Saqqarah, and who was later
regarded as the Egyptian god of medicine and identified with the Greek god
Asclepius. Surer knowledge comes from the study of Egyptian papyri, especially
the Ebers
and Edwin
Smith papyri discovered in the 19th century. The former is a list of
remedies, with appropriate spells or incantations, while the latter is a
surgical treatise on the treatment of wounds and other injuries.
Contrary to what might be
expected, the widespread practice of embalming the dead body did not stimulate
study of human anatomy. The preservation of mummies has, however, revealed some
of the diseases suffered at that time, including arthritis, tuberculosis of the
bone, gout, tooth decay, bladder stones, and gallstones; there is evidence too
of the parasitic disease schistosomiasis, which remains a scourge still. There
seems to have been no syphilis or rickets.
The search for information
on ancient medicine leads naturally from the papyri of Egypt to Hebrew
literature. Though the Bible contains little on the medical practices of Old
Testament times, it is a mine of information on social and personal hygiene.
The Jews were indeed pioneers in matters of public health.
Traditional medicine and
surgery in the Orient
Indian medicine has a long
history. Its earliest concepts are set out in the sacred writings called the Vedas,
especially in the metrical passages of the Atharvaveda, which may possibly date
as far back as the 2nd millennium BC. According to a later writer, the system of
medicine called Ayurveda
was received by a certain Dhanvantari
from Brahma, and Dhanvantari was deified as the god of medicine. In later times
his status was gradually reduced, until he was credited with having been an
earthly king who died of snakebite.
The period of Vedic
medicine lasted until about 800 BC. The Vedas are rich in magical practices for
the treatment of diseases and in charms for the expulsion of the demons
traditionally supposed to cause diseases. The chief conditions mentioned are
fever (takman), cough, consumption, diarrhea, dropsy, abscesses,
seizures, tumours, and skin diseases (including leprosy). The herbs recommended
for treatment are numerous.
The golden age of Indian
medicine, from 800 BC until about AD 1000, was marked especially by the
production of the medical treatises known as the Caraka-samhita
and Susruta-samhita, attributed, respectively, to
Caraka, a physician, and Susruta, a surgeon. Estimates place the Caraka-samhita
in its present form as dating from the 1st century AD, although there were
earlier versions. The Susruta-samhita probably
originated in the last centuries BC and had become fixed in its present form by
the 7th century AD. Of somewhat lesser importance are the treatises attributed
to Vagbhata. All later writings on Indian medicine were based on these works.
Because Hindus were
prohibited by their religion from cutting the dead body, their knowledge of anatomy
was limited. The Susruta-samhita recommends that a
body be placed in a basket and sunk in a river for seven days. On its removal
the parts could be easily separated without cutting. As a result of these crude
methods, the emphasis in Hindu anatomy was given first to the bones and then to
the muscles, ligaments, and joints. The nerves, blood vessels, and internal
organs were very imperfectly known.
The Hindus believed that
the body contains three elementary substances, microcosmic representatives of
the three divine universal forces, which they called spirit (air), phlegm, and
bile (comparable to the humours
of the Greeks). Health depends on the normal balance of these three elementary
substances. The seven primary constituents of the body--blood, flesh, fat, bone,
marrow, chyle, and semen--are produced by the action of the elementary
substances. Semen was thought to be produced from all parts of the body and not
from any individual part or organ.
Both Caraka and Susruta
state the existence of a large number of diseases (Susruta says 1,120).
Rough classifications of diseases are given. In all texts "fever," of
which numerous types are described, is regarded as important. Phthisis (wasting
disease, especially pulmonary tuberculosis) was apparently prevalent, and the
Hindu physicians knew the symptoms of cases likely to terminate fatally. Smallpox
was common, and it is probable that smallpox inoculation was practiced.
Hindu physicians employed
all five senses in diagnosis. Hearing was used to distinguish the nature of the
breathing, alteration in voice, and the grinding sound produced by the rubbing
together of broken ends of bones. They appear to have had a good clinical sense,
and their discourses on prognosis contain acute references to symptoms that have
grave import. Magical beliefs still persisted, however, until late in the
classical period; thus, the prognosis could be affected by such fortuitous
factors as the cleanliness of the messenger sent to fetch the physician, the
nature of his conveyance, or the types of persons the physician met on his
journey to the patient.
Dietetic treatment was
important and preceded any medicinal treatment. Fats were much used, internally
and externally. The most important methods of active treatment were referred to
as the "five procedures": the administration of emetics, purgatives,
water enemas, oil enemas, and sneezing powders. Inhalations were frequently
administered, as were leeching, cupping, and bleeding.
The Indian materia medica
was extensive and consisted mainly of vegetable drugs,
all of which were from indigenous plants. Caraka knew 500 medicinal plants, and
Susruta knew 760. But animal remedies (such as the milk of various
animals, bones, gallstones) and minerals (sulfur, arsenic, lead, copper sulfate,
gold) were also employed. The physicians collected and prepared their own
vegetable drugs. Among those that eventually appeared in Western pharmacopoeias
were cardamom
and cinnamon.
As a result of the strict
religious beliefs of the Hindus, hygienic measures were important in treatment.
Two meals a day were decreed, with indications of the nature of the diet, the
amount of water to be drunk before and after the meal, and the use of
condiments. Bathing and care of the skin were carefully prescribed, as were
cleansing of the teeth with twigs from named trees, anointing of the body with
oil, and the use of eyewashes.
In surgery, ancient Hindu
medicine reached its zenith. Operations performed by Hindu surgeons included
excision of tumours, incision and draining of abscesses, punctures to release
fluid in the abdomen, extraction of foreign bodies, repair of anal fistulas,
splinting of fractures, amputations, cesarean sections, and stitching of wounds.
A broad array of surgical
instruments were used. According to Susruta the surgeon should be
equipped with 20 sharp and 101 blunt instruments of various descriptions. The
instruments were largely of steel. Alcohol seems to have been used as a narcotic
during operations, and bleeding was stopped by hot oils and tar.